<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" 
    "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">

    <head>
        <title>Surco Formulario</title>
		<link rel="stylesheet" type="text/css" href="css/styles.css" />
    </head>

    <body>
        <div class="container">
			<div class="header">
				<div class="headerText">
					RELLENA EL FORMULARIO A CONTINUACI&Oacute;N
				</div>
			</div>
			<div class="clear"></div>
			<div class="mainBody">
				
				<div class="headerFadeContainer">
					<div class="headerFade headerFade1"></div>
					<div class="headerFade headerFade2"></div>
					<div class="headerFade headerFade3"></div>
				</div>
				
				<div class="lapiz_container">
				    <img src="images/lapiz.png" />
				</div>
				
				<div class="form_container">
					<div class="form_questions_container">
						<form class="real_form">
							<div class="form_space_div"></div>
							<div class="input_name input_label">
								<label for="name">Nombre:</label>
								<input type="text" value="" id="name" name="name" />
							</div>
							<div class="clear"></div>
							<div class="input_lastname input_label">
								<label for="lastname">Apellido:</label>
								<input type="text" value="" id="lastname" name="lastname" />
							</div>
							<div class="clear"></div>
							<div class="input_ci input_label">
								<label for="ci">*C&eacute;dula de Identidad:</label>
								<input type="text" value="" id="ci" name="ci" size="8" />
							</div>
							<div class="clear"></div>
							<div class="input_age input_label">
							    <label for="age">Edad:</label>
							    <input type="text" value="" id="age" name="age" />
							</div>
							<div class="clear"></div>
							<div class="input_phone input_label">
							    <label for="phone">Tel&eacute;fono:</label>
							    <input type="text" value="" id="phone" name="phone" />
							</div>
							<div class="clear"></div>
							<div class="input_email input_label">
							    <label for="email">E-mail:</label>
							    <input type="text" value="" id="email" name="email" />
							</div>
							<div class="clear"></div>
							<div class="input_state input_label">
							    <label for="state">Departamento:</label>
							    <input type="text" value="" id="state" name="state" />
							</div>
							<div class="clear"></div>
							<div class="input_school input_label">
							    <label for="school">Escuela:</label>
							    <input type="text" value="" id="school" name="school" />
							</div>
							<div class="clear"></div>
							<div class="input_grade input_label">
							    <label for="grade">Grado:</label>
							    <input type="text" value="" id="grade" name="grade" />
							</div>
							<div class="clear"></div>
							<div class="input_transportation input_label">
							    <label for="transportation">&iquest;En qu&eacute; vas a la escuela?:</label>
							    <div class="clear"></div>
							    <input type="text" value="" id="transportation" name="transportation" />
							</div>
							<div class="clear"></div>
							
							<a class="link_enviar" href="javascript:void(0)">
							    <img src="images/enviar.png" alt="Enviar" />
							</a>
							<div class="clear"></div>
							<label class="input_ci_aclaration">
							    *C&eacute;dula de Identidad sin puntos ni guiones
							</label>
						</form>
						
					</div>
				</div>
			</div>
			
			<div class="clear"></div>
			
			<div class="footer">
				<img src="images/surco-logo-horizontal.png" alt="Surco Seguros" />
			</div>
        </div>

    </body>
</html>
